As with most things complex, the basics are pretty simple.
Patient calls in/arrives, a Case is set up.
First things first – patients have one desire which is to get well, hospitals have scarce resources, doctors are busy.
So, a good strategy is to start discharge planning from the start.
Once, Pt has been through Intake, Assessment, Diagnosis, it’s mostly all about Tx Planning and Monitoring going forward.
We all know about the problems of diagnosis.
Few patients meet all of the criteria for any disease. Some of their symptoms/signs are representative of other diseases. But, Tx plans are typically disease-specific. The application of one Tx template will improve some of the symptoms/signs of one disease to the possible detriment of another condition, so, at the end of the day, blended Tx plans are often needed.
The usual result is Pt will have a number of objectives/goals some of which are more important than others. Tx Plan monitoring needs to focus on attainment of objectives and no two Pts are likely to have the same set of objectives. At a practical level, it is not necessary to meet all objectives in order to discharge.
Coordination of care means aligning all interventions to attaining objectives.
In a hospital, each Pt is likely to receive services from a number of healthcare professionals so Case is the way to go (e.g. call it e-charting if you like). Case gives you at-a-glance access to past interventions and, depending on the sophistication of the implementation, may provide decision support in respect of current and future interventions.
Case gives you a reverse chronological Hx of interventions, each with a date/time-stamp and “signature” of the performing resource. You get to see data, as it was, on the form versions that were in service at the time the data was collected.
Automated resource allocation, levelling and balancing plus background Orchestration and Governance ensures that things do not fall between the cracks and that there are not unwanted significant time delays between interventions.
Interoperability is important “icing on the cake”, linking up local and remote 3rd party systems and applications and providing multi-directional data exchange.